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  • AAO PPP Pediatric Ophthalmology/Strabismus Panel, Hoskins Center for Quality Eye Care
    By the American Academy of Ophthalmology Preferred Practice Pattern Pediatric Ophthalmology/Strabismus Panel: Derek T. Sprunger, MD,1 Scott R. Lambert, MD,2 Amra Hercinovic, MPH, Methodologist,3 Christie L. Morse, MD,4 Michael X. Repka, MD, MBA, Consultant,5 Amy K Hutchinson, MD,6 Oscar A. Cruz, MD,7 David K. Wallace, MD, MPH, Chair8

    As of November 2015, the PPPs are initially published online-only in the Ophthalmology journal and may be freely downloaded in their entirety by all visitors. Open the PDF for this entire PPP or click here to access the PPP on the journal's site. Click here to access the journal's PPP collection page.

    1Indiana University Health Physicians, Midwest Eye Institute, Indianapolis, Indiana
    2Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California
    3Jaeb Center for Health Research, Tampa, Florida
    4Concord Eye Center, Concord, New Hampshire
    5David L. Guyton, MD and Fednuniak Family Professor of Ophthalmology, Professor of Pediatrics, Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
    6Professor of Ophthalmology, Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
    7Anwar Shah Endowed Chair and Professor, Department of Ophthalmology and Department of Pediatrics, Saint Louis University Medical Center, Saint Louis, Missouri
    8Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana

    Highlighted Findings and Recommendations for Care

    Strabismus in children under 4 months of age sometimes resolves without treatment, particularly if the deviation is intermittent, variable, or measures less than 40 prism diopters.

    Repeat cycloplegic refraction is indicated when esotropia does not respond to an initial prescription for hyperopia or when esotropia recurs after surgery.

    Acquired esotropia should be evaluated and treated promptly. 

    Young children with intermittent exotropia and good fusional control can be followed without surgery because there is a low rate of deterioration to constant exotropia or reduced stereopsis.

    Indications for surgery in intermittent exotropia include a progression to constant or nearly constant deviation, reduced stereopsis, and/or a negative effect on social interactions.

    Unilateral recess-resect and bilateral lateral rectus recessions are both effective initial surgical procedures for the treatment of intermittent exotropia.

    Convergence insufficiency occurs in children and adults, and symptoms with near viewing can often be improved using vergence exercises.

    Simultaneous prism and cover testing measures the manifest angle of strabismus, and prism and alternate cover testing measures the total angle of misalignment. Both inform the ophthalmologist’s decisions regarding management and surgical indications.

    Literature Search

    Esotropia and Exotropia PPP - 2022 - Literature Search